Provider Demographics
NPI:1205916871
Name:ANNE M. NICKODEM, MD PC
Entity type:Organization
Organization Name:ANNE M. NICKODEM, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICKODEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-560-8711
Mailing Address - Street 1:3299 WOODBURN RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1275
Mailing Address - Country:US
Mailing Address - Phone:703-560-8711
Mailing Address - Fax:703-560-8725
Practice Address - Street 1:8229 BOONE BLVD STE 365
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2623
Practice Address - Country:US
Practice Address - Phone:703-560-8711
Practice Address - Fax:703-560-8725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047333208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
736626Medicare PIN